Provider Demographics
NPI:1942342613
Name:SMITH, SANDRA R
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:R
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4918 217TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-1351
Mailing Address - Country:US
Mailing Address - Phone:718-224-9136
Mailing Address - Fax:
Practice Address - Street 1:11835 QUEENS BLVD STE 1550
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7215
Practice Address - Country:US
Practice Address - Phone:718-544-5730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5165225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03728HMedicare ID - Type UnspecifiedPROVIDER NUMBER